Journal of Human Development and Capabilities

A Multi-Disciplinary Journal for People-Centered Development

ISSN: 1945-2829 (Print) 1945-2837 (Online) Journal homepage: http://www.tandfonline.com/loi/cjhd20

India, Health Inequities, and a Fair Healthcare

Provision: A Perspective from Health Capability

Rhyddhi Chakraborty & Chhanda Chakraborti

To cite this article: Rhyddhi Chakraborty & Chhanda Chakraborti (2015) India, Health
Inequities, and a Fair Healthcare Provision: A Perspective from Health Capability, Journal of
Human Development and Capabilities, 16:4, 567-580, DOI: 10.1080/19452829.2015.1105201

To link to this article: http://dx.doi.org/10.1080/19452829.2015.1105201

Published online: 03 Nov 2015.

Submit your article to this journal

Article views: 257

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=cjhd20

Download by: [Human Development and Capability Initiative] Date: 12 January 2017, At: 13:17
Journal of Human Development and Capabilities, 2015
Vol. 16, No. 4, 567580, http://dx.doi.org/10.1080/19452829.2015.1105201

India, Health Inequities, and a Fair Healthcare

Provision: A Perspective from Health
Capability
RHYDDHI CHAKRABORTY & CHHANDA CHAKRABORTI
Department of Humanities and Social Sciences, Indian Institute of Technology Kharagpur, Kharagpur,
West Bengal, India

ABSTRACT In India, health inequality, rooted in structural elements of the public

healthcare system, is a topic of much concern and discussion in research literature.
However, very few articles have approached this persistent problem from a theoretical
standpoint. This article addresses this gap by employing the social justice framework of
the Health Capability Paradigm (HCP). After critically analyzing some features of the
Indian healthcare system, the article argues that some public healthcare system features
not only cause health inequalities, but more specically cause inequities in central
health capabilities to avoid escapable diseases and premature death. To address such
inequities, the article argues from an HCP perspective that the Indian healthcare system
should (a) revise the national health policys underlying vision of health, (b) reshape its
three-tiered public healthcare system to deliver healthcare services to all, and (c) focus
on core HCP concepts such as shared health governance and shortfall inequality as
guiding principles to provide universal health coverage to all.
KEYWORDS : Capabilities, Health, India, Inequality

1. Introduction
Health inequalities based on biological differencesthe gap in average life expectancy
between women and men, for examplecannot reasonably be described as unfair. These
inequalities are not preventable or remediable. However, health inequalities may also be
socially constructed and can be unnecessary, avoidable, unfair, and unjust (Whitehead
1992). Such ethically unacceptable inequalities, caused by various social and economic
factors (popularly known as social determinants of health or SDH), are termed health
inequities (CSDH 2008). SDH may be external or internal to the healthcare system, but
affect and determine the health of individuals and populations living under them. Examples
of such external determinants of health include housing, education, race, caste, class,
income, gender, and social exclusion. Internal healthcare system factors appear on both
the supply and demand side of healthcare service delivery, and include, inter alia,

Correspondence Address: Rhyddhi Chakraborty, Department of Humanities and Social Sciences, Indian Institute
of Technology Kharagpur, Kharagpur, West Bengal, India. Email: rhyddhi_414@yahoo.co.in, rhyddhi.
chakraborty@gmail.com

2015 Human Development and Capability Association

568 R. Chakraborty & C. Chakraborti

human resources, funding, and the use of services (Balarajan, Selvaraj, and Subramanian
2011). This article about healthcare in India focuses on some of these internal factors.
In India, health inequity1 is a harsh reality. Health inequities vary according to social and
economic groups as well as across geographical regions (Baru and Bisht 2010). The Sched-
uled caste (Sc),2 Scheduled tribe (ST), socially and educationally disadvantaged people
(constitutionally known as other backward classes or OBC (GoI 1980)), and the rural popu-
lations of the poorest states such as Uttar Pradesh, Bihar, Chattisgarh, Manipur, and Assam
are more at risk of poor health than other members of society (Baru and Bisht 2010; ET
2014; WB 2015). Thus, children of the Scheduled caste are at higher risk of having
anemia than children of the other social groups (Vart, Jaglan, and Shaque 2015). The
tribal child born in India reportedly has a 50 percentage higher risk of dying before age
5 than the children of nontribal groups (Baru and Bisht 2010). Members of the poorest quin-
tile suffer under-ve mortality (U5MR) three times higher than those in the richest income
quintile (Baru et al. 2010, 49).
Numerous researchers claim that these health outcome variations result largely from
differences in availability, accessibility, affordability, quality, and utilization of healthcare
services (Baru and Bisht 2010; Balarajan, Selvaraj, and Subramanian 2011; Bhagwati
and Panagariya 2013; Dreze and Sen 2013). Some further claim that in a country such as
India, differential qualities of healthcare service delivery and the inequalities in health
service availability, accessibility, utilization, and affordability inuence overall health dis-
parities across regions, states, and segments of the population (Minnery et al. 2013); or,
more denitively, that these inequalities cause Indias health inequities (Baru et al. 2010;
Balarajan, Selvaraj, and Subramanian 2011).
Researchers, social scientists, healthcare experts, and health policy analysts prescribe
wide-ranging recommendations to address these health inequities. These recommen-
dations3 include reformation of the whole healthcare sector (Dreze and Sen 2013), bringing
healthcare services under a local and national regulatory body (Bhagwati and Panagariya
2013), and investments in primary care services, application of certain principles (Balara-
jan, Selvaraj, and Subramanian 2011). But even though comprehensive, these recommen-
dations fall short because they lack an undergirding theoretical foundation.
To ll this gap, this article draws on the social justice framework of the Health Capability
Paradigm (HCP). It argues that health inequities caused by the Indian healthcare system and
service delivery are not only inequities in health outcomes. Rather, they are inequities in the
capabilities to avoid escapable disease and premature death. To address such inequities, the
article argues for a change in the underlying vision of health in Indian national health policy.
In addition, this new vision requires reconsidering the three-tiered public health system and
incorporating HCP principles like shared health governance and shortfall inequality into
the Indian health architecture. Together, these reconsiderations will shape a just vision
for healthcare policy reform and help restructure the healthcare system to address central
health capability decits.
This article begins by demonstrating how features of the public healthcare system con-
tribute to inequities in the capability to avoid escapable diseases and premature deaththe
central health capabilities. The health systems most signicant inequities occur at this
central health capabilities level. It then turns to key HCP concepts for guidance in addres-
sing these inequities. As the rst application of the capability approach to health (Ruger
1998, 2003, 2004, 2006a, 2006b, 2006c), the HCP and its antecedents, developing the
eld of capabilities and health, offers the most attractive theoretical and empirical approach
for such analysis. Finally, the article, grounded in the social justice theory of the HCP, puts
forth recommendations for the required vision of health, changes in the three-tiered public
 India, health inequities, and a fair health care provision 569

health system, and steps to incorporate shared health governance and shortfall inequality in
the Universal Health Coverage (UHC) scheme to bring about fair provision for all.

2. Indian Healthcare System, Health Inequities, and Inequity in Health Capability

Both public and private healthcare structures constitute the Indian healthcare system.
Responsibility for the public sector lies with the Indian government, but the sector is
divided into three levels: central, state, and village or Panchayat level. This government-
funded system is a three-tier system, with primary, secondary, and tertiary tiers. The
primary tier, which consists of the Sub-Center (SC)/Primary Health Center (PHC),
addresses health problems of the rural population. The Community Health Center
(CHC), sub divisional, and district hospitals form the second tier. Teaching hospitals and
other specialized hospitals form the third and tertiary healthcare level (Baru et al. 2010,
50; Acharya 2012, 5455; Agnihotri 2012, 6). Unfortunately, this system is deeply
inadequate for Indias teeming population. Public health sector expenditures are less than
4 percentage of GDP (UNDP 2014). As a result, many complain about unequal access;
low quality of care, diagnostics, and infrastructure; and a shortage of healthcare resources.
To address some of these issues, the National Rural Health Mission (NRHM) was launched
in 2005 by the Government of India (GoI) (Baru et al. 2010, 5657) but its performance has
been questioned (Sharma 2009; WG 3 (1), GoI 2011a, 7).
Researchers charge that the crisis in healthcare service delivery actually lies in its
massive inadequacies in government spending and its emphasis on private healthcare
service delivery and private insurance schemes (Dreze and Sen 2013, 143181). They
also cite nutritional failure, long-standing neglect of childcare services, and the mere
absence of public discussion of such inadequacies (Dreze and Sen 2013, Ibid.). As a sol-
ution, these scholars recommend a new commitment to UHC by refocusing on the rst tier
of healthcare service deliverythat is, on primary healthcare centersto deliver timely
care on a regular basis; more public involvement in health issues; enhanced democratic dis-
cussion of health and healthcare issues; and the application of lessons learned in other
nations and states (Dreze and Sen 2013, 177181). The emphasis on UHC and open
public discussion are valuable. But this prescription neglects the collective responsibility
necessary to secure fair provision of healthcare to all. Nor does it specify how exactly to
renew focus on primary care centers. It also does not specify the standard of quality for
primary care service delivery, and what is to be the underlying vision behind it.
Highlighting ve key areas of the Indian healthcare systems needing reformation,
another group of researchers argues that the crisis of Indian healthcare involves public
health inadequacies, routine healthcare, hospitalization and outpatient surgeries, human
resources, and overall oversight of the system (Bhagwati and Panagariya 2013, 177
188). To these researchers, a systematic and substantial national-level regulation of health-
care services using a bottom-up approach and a strong scientic foundation for analysis can
reform the healthcare system (Bhagwati and Panagariya 2013, 177, 188). The value of this
recommendation lies in its emphasis on a bottom-up strategy. However, a bottom-up
approach opens up different kinds of needs (regional, socioeconomic, and medical), and
this proposal does not explain how to prioritize and address these needs. Additionally,
addressing many serious health system issues, especially equity issues, require not just
scientic analysis but also ethical reasoning. Healthcare reform under this regulatory
approach might also produce a one size ts all strategy, which could overlook the neediest
and foster its own inequities. Nor does this approach recognize the need for theoretical
grounding in a theoretical framework such as the HCP.
570 R. Chakraborty & C. Chakraborti

Other researchers cite imbalanced resource allocation, limited physical access to quality
health services, high out-of-pocket (OOP) health expenditures, health spending ination,
and behavioral factors affecting the demand for appropriate health care (Balarajan, Selvaraj,
and Subramanian 2011). They recommend measures such as equity metrics in monitoring,
evaluation and strategic planning; investment in a rigorous knowledge-base of health
systems research; more equity-focused deliberative decision-making in health reform;
and redenition of the specic responsibilities and accountabilities of the key actors (Balar-
ajan, Selvaraj, and Subramanian 2011). The recommendations, particularly the latter two,
are useful in highlighting the demand side of the healthcare system. However, their rec-
ommendations are strategic, without any strong theoretical foundation, and they lack pro-
vision for in-depth insight about where exactly inequity lies and why it demands redress.
Despite these gaps, these recommendations are indispensable for healthcare reform in
India. But we also need moral insight, theoretical guidance to address the deep ethical
issues involved. Specically, we need an underlying vision of health grounded in a
strong theoretical foundation (Ruger 1995) and incorporating key theoretical concepts in
the UHC scheme (Ruger 2008).
The following section explains how some features of the Indian healthcare system cause
inequities in central health capabilities.

2.1. Some Factors of Healthcare System and Health Inequities

(a) Healthcare Financing and Expenditure: Public expenditures on health in India are low,
less than 4 percentage of GDP (UNDP 2014). The private sector4 has grown substantially,
and its burgeoning growth is visible at all three levels (Agnihotri 2012). Findings of the last
National Family Health Survey (NFHS)-3 (20052006) show that, due to public sector
inadequacies, the private sector is the primary source of health care for over 70 percentage
of urban households and 63 percentage of rural households (MoHFW 2007)4. This is one of
the main reasons why such a large number of people in India are forced to incur heavy OOP
expenses for private medical services, both for in-patient and outpatient care (Jacob John
et al. 2011). In 20112012, the share of OOP expenditures on healthcare as a proportion
of total household monthly per capita expenditure was found to be 6.9 percentage in
rural areas and 5.5 percentage in urban areas.
Hospitalizations, even in public hospitals in India, have led to catastrophic health expen-
ditures, and over 63 million persons confront poverty every year due to healthcare costs
alone (NHP (Draft) 2015, MoHFW, GoI 2014, 8). This burden has been especially true
in rural regions, where about 70 percentage of the Indian population lives. Half of them
live below the poverty line and face major access and affordability barriers for quality
healthcare services. Some of the direct consequences of such high healthcare expenditures
are (a) selling of the households resources, (b) cutting the healthcare consumption of other
family members, and (c) borrowing money from lenders and slipping into debt (Baru et al.
2010, 5354). In short, low government healthcare spending and high private healthcare
expenditures push some groups of people down the socioeconomic ladder, where they
face more socioeconomic vulnerabilities. It also forces them to compromise on medical
needs and to ration care for themselves and their families, thus further undermining their
health.
This high healthcare spending also forces people to compromise on nutrition and makes
them vulnerable to diseases and death that could otherwise be avoided. A GOI report shows
that these accessibility barriers are related to a rise in poverty-related malnutrition among
some people (11FYP, GoI 2008, Vol.2, 129; Baru et al. 2010, 5657). Research has also
found that especially marginalized groups, who lack access to and utilization of health
 India, health inequities, and a fair health care provision 571

care, have higher rates of malnutrition resulting in anemia, morbidity, and mortality (Chat-
terjee and Sheoran 2007, 8). And malnutrition also links to other killer diseases such as
HIV/AIDS (11 FYP, GoI 2008, 129) and acute lower respiratory tract infections (Kumar
and Quinn 2012). These exposures and susceptibilities could be avoided if these groups
were spared high healthcare expenditures.
In sum, low government spending on the healthcare system and high out of pocket
healthcare expenditures make some people more vulnerable, both socioeconomically and
medically, thereby creating inequities in social conditions as well as in health. Unjust sus-
ceptibility to malnutrition-linked diseases, especially resulting from high out-of-pocket
expenses, implies that low public spending on health care and high personal healthcare
expenditures diminishes central health capabilities.
(b) Hospital Allocation and Capacity: India has a 20 percentage shortfall of Sub-Centers,
24 percentage for PHCs, and 37 percentage for CHCs, particularly in Bihar, Jharkhand,
Madhya Pradesh, and Uttar Pradesh (12th FYP 2013, III: 5). As of the last district level
household and facility survey (DLHS III 20072008), at the all-India level, 49,193
persons are served by a single PHC, while the norm is to serve 30,000 persons in plain
areas and 20,000 persons in hilly or tribal areas. And in many major states of India such
as Bihar, West Bengal, Uttar Pradesh, Haryana, and Chandigarh, more than 150,000
people are served by one CHC (DLHS III (20072008), IIPS 2010: 214). The secondary
and tertiary level public hospitals are largely built in urban areas and developed states
(Baru et al. 2010). And failure to develop public hospitals in proportion to population
growth and health needs has fostered growth in the private and corporate hospital
sectors. In particular, private tertiary care has grown in the southern states, urban metropo-
lises, and other well-off regions (Baru et al. 2010; WG (2), GoI 2011b: 15). These inade-
quacies in the number of care centers at the primary level and hospitals at the secondary
and tertiary levels imply inadequate provision of timely care and treatment.
In hospital capacity (hospital beds, child birth facilities, diagnostic facilities, availability
of medicines, and healthcare staffs), India has a current public sector availability of one bed
per 2012 persons available in 12,760 government hospitals, or approximately 0.5 beds per
1000 (Planning Commission 2011a, 186). The number of beds in government hospitals in
urban areas is more than twice than in rural areas (Balarajan, Selvaraj, and Subramanian
2011). In addition to this variation, differences in the allocation of beds appear among
the states. In 2008, there were an estimated 11,289 government hospitals with 494,510
beds, with marked regional variation ranging from 533 persons per government hospital
bed in Arunachal Pradesh to 5494 persons per government hospital bed in Jharkhand
(Balarajan, Selvaraj, and Subramanian 2011). This disparity in the allocation of beds
implies severe difculty for some in accessing appropriate and adequate care.
As to diagnostic and critical care units, some have alleged that most public hospitals and
medical colleges in India either have no viral diagnostic facilities (Jacob John 2005), or no
intensive care units or ventilators (Jacob John and Muliyil 2009). Moreover, most of the
critical units have been created at the district level, that is, in the urban facilities, thereby
ignoring rural health needs (Jacob John and Muliyil 2009). Critical care units in hospitals
at all levels bolster the capacity to address public health emergencies such as A H1N1,
annual epidemics of dengue, chikungunya, and malaria. They can also help people seek
timely diagnosis and treatment, and can help avoid needless loss of life.
This differential distribution of healthcare centers, hospitals, and critical care facilities
has caused access barriers to some groups and individuals across geographical locations
and socioeconomic factors (Deogaonkar 2004) and has given rise to inequities, especially
at the level of health-seeking behaviorsthe ability to seek appropriate, adequate, and
timely care and avoid disease and death.
572 R. Chakraborty & C. Chakraborti

(c) Healthcare Human Resources: Like the inadequacies of hospitals, there is a dearth of
healthcare human resources in India. Though government reports discuss recruitment, stat-
istics do not match reported numbers. A recent government report, for example, states that
nearly 150,000 skilled persons joined the Public Health System in the last 6 years under
NRHM. Of these, 41 percentage are ANMs (antenatal nurse and midwives, responsible
for taking care of rural womens reproductive health), 20 percentage are staff nurses, and
14 percentage are medical ofcers including Allopathic and AYUSH doctors (the indigen-
ous system of medical practice involving Ayurveda, Yoga and Naturopathy, Unani, Siddha
and Homeopathy) (MoHFW, GoI 2011, 40). This report also states that since June 2010,
1334 Bachelor of Medicine, Bachelor of Surgery doctors, 2003 specialists, 4892 staff
nurses, and 3079 AYUSH doctors were added into the system along with 14,711 ANMs
at the rural Sub-Centers (MoHFW, GoI 2011, Ibid.). However, in reality, low public health-
care funding has resulted in staff shortages at hospitals as well as in healthcare centers, and
there are complaints about low quality in care and diagnostic facilities, especially in rural
areas. Low quality care hinders opportunities to be healthy, obstructs health functionings,
and hampers the ability to pursue health goals that one values.
Researchers found that in 2010, 10 percentage of posts of doctors at the PHCs, 63 per-
centage of the specialist posts at the CHCs, 25 percentage of the nursing posts at PHCs and
CHCs combined, 27 percentage pharmacist posts, and 50 percentage of laboratory tech-
nician posts were vacant (Yeravdekar, Yeravdekar, and Tutakne 2013). These PHCs and
CHCs are located in rural regions; so these rural areas suffer most from these shortages
(Balarajan, Selvaraj, and Subramanian 2011). These rural populations thus lack timely
and appropriate care; adequate diagnosis and treatment; and sufcient information about
health, disease, and potential medical consequences. Adequate health center stafng
would signicantly diminish these health threats.
Beside shortages in human resources and adequate service delivery, rural areas also
suffer from ill-trained and ill-equipped personnel. A cross-sectional descriptive study
carried out among 225 Accredited Social Health Activists (ASHAs) in the southern state
of Karnataka, between June and July 2011 found that ASHAs were poorly equipped to
identify obstetric complications or to help expectant mothers draw up birth preparedness
plans. Ironically, these ASHAs are to act as a link between pregnant women and health
facilities and are trained to foster participation in Janani Suraksha Yojana (JSY, a safe
motherhood intervention scheme to reduce neonatal and maternal deaths), institutional
delivery, and immunizations (MoHFW, GoI 2011). As part of the NRHM, they are also
required to have a birth preparedness plan and make pregnant mothers aware of the
danger signs of complications to initiate appropriate and timely referral to obstetric care
(Kochukuttan, Ravindran, and Krishnan 2013). However, while more than 800,000
women have been trained and deployed as ASHAs at the village level, till 2011 only
690,000-plus had received proper drug kits (MoHFW, GoI 2011).
This shortage of healthcare personnel, especially the ill-equipped staffs, affects access to
and use of appropriate care. It has also affected immunization status across regions and
groups. While all-India immunization coverage is low (44 percentage), the coverage in
the highest income quintile (71 percentage) is three times than in the lowest quintile
(24.4 percentage). And there is a substantial gap in immunization coverage between the
STs (31.3 percentage) and others (53.8 percentage) (Baru et al. 2010). These disparities
in immunization due to staff shortages have led to differential health status and disparities
in the capability to avoid many life-threatening diseases.
In sum, factors internal to the healthcare system affect some groups, differentiated by
geography, class, and caste, more than other, often by depriving these groups of information
about health and disease and of equal access to timely, appropriate, adequate diagnosis and
 India, health inequities, and a fair health care provision 573

treatment. These factors affect the individuals or groups actual and potential health. Con-
sequently, the affected groups have different abilities to meet their health needs, to pursue
the health and life goals they value, and to adjust to and overcome new situations. As a
whole, these healthcare-related factors hinder individuals ability to avoid preventable dis-
eases and premature death and thus exacerbate health inequities.5
To address such inequities in central health capabilities, the Indian healthcare system
should provide fairly for all. And that needs reform at a much deeper level, beyond the
healthcare system. The social justice framework of the HCP provides the requisite founda-
tional framework. The next section provides an overview of such a paradigm along with a
discussion of health capability inequities arising from the healthcare system.

3. Health Capability: A Social Justice Theoretical Framework

Health Capability, a social justice framework for the reform of healthcare systems, health
policy, and public health policy (Ruger 1998, 2004, 2006a, 2009), has roots in, yet extends
signicantly beyond, the capabilities approach6 as propounded by Sen (1984, 1992, 2004,
2009) and Nussbaum (1997, 2001, 2003). With its roots in capability theory, the HCP, as
created by J.P. Ruger, conceives health capability as a persons ability to be healthy and
assigns a special moral importance to health capability, which signies more than simple
physiological health. Ruger denes it as, the ability of individuals to achieve certain
health functionings as well as the freedom to achieve those functionings (2009, 81).
Here health functions mean avoiding disease, deformity, malnutrition, and disability; and
reaching normal life expectancy. Freedom is the freedom of choice to pursue these func-
tions. And individuals are agents who value certain health and life goals. Ruger identies
the core health capabilities as the capability to avoid preventable disease and premature
death, conditioned by social, economic, political, and other factors (Ruger 1998, 2009,
4). These central health capabilities, as Ruger maintains, are not directly observable and
measurable (2009, 81), but their component partshealth functioning and health agency
(Figure 1)are. Health functioning is health status or health performance. Health function-
ings of any group or individuals, Ruger species, can be known from existing health indi-
cators and health performance based on those indicators (Ruger 2009, 8, 8183). Good
health functionings require collective societal obligations to ensure and enable the con-
ditions for all to be healthy.
Health agency, the other component of health capability, is the ability of the group or
individual to pursue valuable health goals (Ruger 2009, 82). More specically, health

Figure 1. Health capability, health agency, health functioning.

Source: Ruger (2009, 82).
574 R. Chakraborty & C. Chakraborti

agency includes health knowledge, effective decision-making in health matters, self-man-

agement, and self-regulation skills (Ruger 2009, 146148; 2010). And with health agency,
Ruger incorporates individual responsibility for using healthcare and other societal
resources and conditions to achieve maximal levels of health functioning. For, even if
society guarantees equal access to healthcare, individuals must exercise their health
agency to translate these resources into good health (Ruger 2009, 146148).
Ruger claims that inadequacies in the healthcare system ultimately affect both central
health capabilities and overall health capability. Therefore, according to Ruger, inequalities
in health are actually inequalities in health capabilities and specically in central health
capabilities. These health inequalities prevent people from achieving good health.7 She
calls these deprivations shortfall inequalities; shortfalls of actual achievement from the
optimal average. Ruger also suggests that these inequalities are social justice failures,
unjust because they arbitrarily and unnecessarily reduce the capability for health function-
ing, and especially affect central health capabilities.
Because the healthcare system is a core determinant of health, Ruger further claims that
health systems must offer individuals the prerequisites for a healthy life and positive health
determinants. Those prerequisites within the healthcare system should be distributed equi-
tably and should conform to high-quality standards effectively and efciently. As part of the
social justice obligation, society, through the government, should guarantee equal access to
appropriate preventive measures and high-quality treatment.
She also argues that the public healthcare system and individuals have a shared obli-
gation to create conditions where all can exercise health capability. She introduces the
concept of shared health governance, a construct in which individuals, providers and
institutions work together to empower individuals and create an environment enabling all
to be healthy (Ruger 2009, xiii; 2011). Shared health governance also requires universal
health insurance coverage via shared costs and risk pooling, with health care funded
through community-rating and progressive nancing. It also argues for collective responsi-
bility to enable equal access to high-quality care and expanded health agency by means of
reasoned consensus, a joint scientic and deliberative process, and analyzing both
clinical and economic factors for evidence-based decision-making (Ruger 2008, 1758).
As a paradigm, the HCP proposes measuring the quality of healthcare by its ability to
address functional impairments arising from injury or illness. And the impact of health
care on individuals health capability is assessed by examining health needs, health
agency, and health norms (Ruger 2009). Health needs are directly observed through
health functionings; health agency is judged through the shortfall of actual achievements
from an agreed-upon optimum. Health norms are societal norms about health that
govern the environment in which individuals navigate choices for healthier life (Ruger
2007). To address inequities in health capabilities, to help people to transform healthcare
resources into optimal health functionings, these norms, Ruger suggests, need to be
closely scrutinized, because norms can be either positive or negative and destructive.
According to the HCP, people become vulnerable and insecure when they lack access to
necessary healthcare services. As a social justice framework, HCP focuses on vulnerability
and insecurity. It is concerned with individuals exposure to risk and their ability to ade-
quately manage it (Ruger 2006d).
Low public spending and high personal OOP healthcare expenses, as mentioned before,
affect peoples ability to avoid disease and premature death. In HCP terms, they adversely
affect central health capabilities and cause inequities in health capability as a whole. OOP
can actually restrict access to healthcare services, and thereby diminish the freedoms to
pursue needed healthcare services (Ruger 2012). This barrier also impedes decision-
making abilities and consequently affects health management abilities and health
 India, health inequities, and a fair health care provision 575

performance skills; that is, it affects health agency as well as health functionings. Besides
directly hampering individual health agency and health functionings, it affects other related
agencies. Thus, in the case of India, when OOP leads to cutting the healthcare consumption
of other family members, it diminishes those persons health agency. They then face depri-
vations in healthcare services and discrimination due to their ill health. And consequently,
their health performances are undermined. Thus groups or individuals fall short from
optimal health; they face deprivation in pursuing their health and life goals, and face
increased risk of preventable disease and premature death. Thus occur shortfall inequalities
in central health capabilities.
The lack of appropriate and effective distribution of resources, as mentioned before, leads
to late identication and diagnosis of disease and inadequate protection for some groups or
individuals. And consequently, those groups or individuals suffer more than others in the
quality of care provided. In India, when distribution of healthcare centers, hospitals, diag-
nostic facilities, and critical care units varies by geographical location, it undermines some
peoples potential to avoid escapable disease and premature death.
A shortage of well-trained healthcare personnel not only hinder delivering quality and
timely care, but also affects individual health agency and health performances. Ill-equipped
and unskilled healthcare workers and the inefciencies they cause prevent effective, ef-
cient, and quality service delivery. And as a consequence, some individuals lack infor-
mation about disease risks, health status, and how to protect against preventable disease
and premature death. Similar inequities occur when a shortage of healthcare workers
affects immunization and fails to cover all targeted people, as happens in India. As a
whole, these shortages create inequities in health capabilities by affecting health agency,
health status, and central health capabilities among groups.
Though it seems that the factors affecting the accessibility, availability, quality, and util-
ization of healthcare services are causing inequities in health outcomes or health function-
ings, in actuality, the inequities appear at much deeper level, at the level of central health
capabilities. To address such inequities, reforming the healthcare system and service deliv-
ery in India must be based on a strong theoretical foundation of social justice. Having a
strong theoretical foundation would help not just in strategizing the means to address
such inequities, but also in developing a guiding vision to implement such strategies. Rec-
ommendations for addressing such inequities based on the HCP follow.

4. Recommendations
(a) Health Policy and the Underlying Vision of Health: To address inequities in central
health capabilities and to enable a healthcare system to provide fairly for all, health
policy in India should reconsider its underlying vision of health.8 It is health policy that
shapes and organizes a healthcare system. Viewing health as a capability and building
upon the HCP as the foundational premise adds special moral importance to health itself
and redresses inequities, keeping the variation in individual capabilities in view. Moreover,
the goal of minimizing premature deaths and preventing escapable disease (i.e. ensuring
central health capabilities) becomes a multi-sectoral action plan with the shared responsi-
bility of different actors in individual and population health.
Health as a capability also emphasizes the importance of the individual in managing
social, economic, environmental, and personal factors as part of health-seeking behavior.
More specically, it focuses on the individuals ability to adjust to, manage, and overcome
risks and conditions created by disease and injury and affected by socioeconomic factors.
And health as a capability also implies a capability to live up to average life expectancy. It
indicates a potential to achieve an optimal average. In sum, health policy when grounded in
576 R. Chakraborty & C. Chakraborti

the underlying vision of the HCP can shape a just healthcare system that accounts for indi-
vidual and population health needs, health agency, health performance, and health norms.
Viewing health as a capability in Indian national health policy grounds the reallocation of
healthcare resources without any geographical or socioeconomic discrimination.
(b) Reconsideration of The Three-Tier Public Healthcare System: Though the Indian
public healthcare system has been organized and functions at three different levels with
the aim to deliver health to all, the system suffers from inadequacies, especially in
funding and human resources. As a result, it fails to reach every individual, to deliver
health to all, and to make a fair provision for all. This failure to reach every individual
deprives some and creates inequities in health. In HCP terms, this lack of fair provision
leads to inequities in the capability to avoid premature death and preventable disease. To
address such inequities in health capabilities, the health system should reconsider its
three-tier system and should try to deliver the highest attainable standard of health to all.
Rather than having differential resources and infrastructure at primary, secondary, and ter-
tiary levels, the healthcare system at the village, district and state level should be equipped
adequately to provide high-quality care equally to all with increased government spending
on health and the healthcare system. This implies, for instance, deploying critical care units,
not just in all district hospitals, but also at the health center level, so that care is available at
the primary level to avoid preventable disease and premature death.
(c) Universal Healthcare Coverage and its Underlying Notion: In India, the High Level
Expert Group has dened UHC as follows:

Ensuring equitable access for all Indian citizens in any part of the country, regardless
of income level, social status, gender, caste or religion, to affordable, accountable and
appropriate, assured quality health services (promotive, preventive, curative and reha-
bilitative) as well as services addressing wider determinants of health delivered to indi-
viduals and populations, with the Government being the guarantor and enabler,
although not necessarily the only provider of health and related services. (Planning
Commission 2011)

With this denition, UHC in India looks to provide opportunities, but does not accept full
responsibility for the provision of equitable access. Moreover, with its focus only on ensur-
ing, UHC in India also overlooks the utilization abilities of individuals and groups. To
address the inequities in central health capabilities and to provide healthcare service for
all, UHC should both ensure and provide opportunities to achieve optimal health. When
opportunities are provided, individuals and groups can exercise their fullest potential to
pursue health and life goals. To do that, UHC should adhere to two core concepts of
HCP, shortfall inequality and shared health governance. The shortfall inequality concept
helps identify the neediest areas or populations and the gaps in service delivery. Shared
health governance can guide the UHC scheme to shoulder the responsibility together
with institutions, individuals, communities, and providers to enhance individuals health
agency and create a social environment that enables all to be healthy (Ruger 2008,
1751). These two concepts act as the guiding principles for identifying populations
failing to reach target health status benchmarks, and for undertaking the collective respon-
sibilities of ensuring and providing equitable healthcare access. The UHC should also adopt
a universal health insurance coverage via shared costs and risk pooling, with health care
funded through community-rating and progressive nancing (Ruger 2008, 1757). With a
community-rating, everybody pays equally, regardless of health status; progressive nan-
cing establishes higher tax rates for the wealthy to fund a functional health system
(Ruger 2008). Continuous universal health insurance should protect all individuals at
 India, health inequities, and a fair health care provision 577

all times, regardless of changes in income, employment, or marital or health status (Ruger
2008, 1758) from risk, both medical and nancial, and enhance security and health capa-
bility (Ruger 2006d).
In the Indian context, high OOP expenses prevent people from seeking medically necess-
ary and appropriate healthcare services. Using HCP principles, the health system could
bring all under the UHC umbrella and provide all with the opportunity to pursue good
health.
To address high OOP, the Indian government in 2008 introduced a national health insur-
ance scheme or The Rashtriya Swasthya Bima Yojana for people below the poverty line.
Under this scheme, government pays the insurance premium; people are entitled to Rs
30,000 and may choose their healthcare institutions from the list of accredited health
centers and hospitals (Dreze and Sen 2013, 152). While this is a step toward addressing
healthcare-related inequities, HCP principles would require that this insurance scheme
cover every citizen, rather than just some.

5. Conclusion
This article has sought to highlight sources of inequities in health capabilities in India.
Addressing health inequities at the level of health outcomes only is nave. National
health policy should reconsider its underlying vision of health; the healthcare system in
India should reconsider its three-tiered system, its conception of UHC to address pervasive
inequities in central health capabilities. If it re-imagines health care according to HCP prin-
ciples, the healthcare system can not only address the current unjust inequities in health
capabilities, but can also provide health services fairly for all.
The social justice theory of the HCP (Ruger 2009) is the relevant foundation. The HCP
introduces social justice to the health domain by drawing our attention to health inequities.
Through core concepts such as central health capabilities, shortfall inequalities, and shared
health governance, this foundational theory argues for collective social obligations, indi-
vidual responsibility to use resources effectively and efciently, and most importantly,
for promoting health capabilities to raise persons and populations to benchmark goals of
health achievement.

Acknowledgement
An earlier version of the paper entitled Pandemic A H1N1 (2009) Preparedness Efforts,
Compliance, and Some Ethical Considerations: A Retrospective Study on Hijli Rural Hos-
pital (RH), Kharagpur I, West Bengal, India was presented at the 12th World Congress of
Bioethics held in Mexico City, June 2528, 2014. Authors are thankful to the organizers of
the conference for this opportunity. The authors are also thankful to the two anonymous
reviewers and editors for their valuable insights and helpful comments.

Disclosure Statement
No potential conict of interest was reported by the authors.
578 R. Chakraborty & C. Chakraborti

Notes
1. A historical review of Healthcare-related inequities in India revealed that three forms of inequities have domi-
nated Indias health sector; (a) historical inequities having roots in the policies and practices of British colonial
India; (b) socio-economic inequities manifested in caste, class, and gender differentials; and (c) inequities in the
availability, utilization, and affordability of health services (Baru et al. 2010).
2. Caste is one of the major socioeconomic determinants in India. Of the four castes, ofcially dened, Scs are
lower in the hierarchy, largely rural and landless agricultural laborers. STs are the adivasis or tribals and
face a similar kind of socioeconomic deprivation as the Scs (Baru et al. 2010, 49).
3. Space does not allow elaboration of the vast range of prescriptions here, and the recommendations stated here
are also not exhaustive in nature.
4. The private sector accounts for 93 percentage of all hospitals, 64 percentage of all beds, 8085 percentage of all
doctors, 80 percentage of out-patients, and 57 percentage in-patients (Planning Commisssion 2011, 192).
5. In spite of these shortages, there are some notable success stories of prevention and eradication of some infec-
tious diseases in India. For example, in 2012, WHO has ofcially declared India as polio-free. The success in
this case has been attributed to a sustained and concerted effort, to an amalgamation of several factors, such as
the very wide coverage of campaigns, improved surveillance among population, enhanced community moni-
toring status, and herd immunity. Most importantly, the success, as a whole, has been linked to the effort in
identifying and addressing the gaps in the coverage on the basis of geographical location and of the socioeco-
nomic background of the population groups (Chakraborty 2014).
6. The central claim of the capability approach is that assessment of justice and injustice should be in terms of each
individual persons capability or freedom to achieve a level of functionings. It involves the individual exercising
the choice to achieve a state of well-being. This approach conceives of creating the most conductive possible
social conditions, i.e. arranging social, political and economic institutions so that adequate material and social
resources are available to all, enabling them to possess and exercise a set of basic capabilities that help them lead
a ourishing life (Alexander 2008).
7. Here Ruger adheres to the Aristotelian concept of human ourishing and health as the end of social and political
activities. That is, good health involves participating in different social activities, being able to pursue further
life goals.
8. In India, health has been conceived sometimes as a state of balance, as an adjustment with physical, social
environment, as basis of economic development, as a constituent of quality of life, a complete state of physical,
social, and mental well-being (GoI 1946:7, 1st FYP 19511956, GoI 2012: chp32, 6th FYP 19801985, GoI
2012: chp 22, 12th FYP 20122017, GoI 2013: 20.1), and as a right as in The National Health Bill Draft
(MoHFW 2009). However, these denitions seem to recognize that economic development, but not total
human development, is the only mark of a developed country. And health when considered merely as a
right, it acts as an equalizer, rather capturing the diverse health needs of the population.

References
Acharya, Sanghamitra S. 2012. Social Discrimination in Health Care Access, Among Dalit Children, Exploring
Inclusive Environment. New Delhi: Indian Institute of Dalit Studies.
Agnihotri, Anustubh. 2012. Patterns of Regional Disparity in Health Outcomes in India, Master Thesis, The
University of Texas, Austin.
Alexander, John M. 2008. Capabilities and Social justice, the Political Philosophy of Amartya Sen and Martha
Nussbaum. Farnham, Surrey, England: Ashgate Publishing Limited.
Balarajan, Yarlini, S. Selvaraj, and S. V. Subramanian. 2011. Health Care and Equity in India. Lancet 377 (9764):
505515.
Baru, Rama, A. Acharya, S. Acharya, A. K. Shiva Kumar, and K. Nagaraj. 2010. Inequities in Access to Health
Services in India: Caste, Class and Region. Economic & Political Weekly xlv (38): 4958.
Baru, Rama V., and Ramila Bisht. 2010. Health Service Inequities as Challenge to Health Security Oxfam India
working Articles series. OIWPSIV. New Delhi: Oxfam India.
Bhagwati, Jagdish, and Arvind Panagariya. 2013. Why Growth Matters, How Economic Growth in India Reduced
Poverty and The Lessons For Other Developing Countries. New York: Public Affairs.
Chakraborty, Rhyddhi. 2014. Ethics in Pandemic Inuenza Preparedness Plan: A Perspective from Social Justice.
PhD Thesis, Indian Institute of Technology, Kharagpur.
Chatterjee, Chandrima, and Gunjan Sheoran. 2007. Vulnerable Groups in India. Mumbai: Centre for Enquiry into
Health and Allied Themes.
 India, health inequities, and a fair health care provision 579

Commission on Social Determinants of Health (CSDH).World Health Organization (WHO). 2008. Closing the
Gap in a Generation: Health Equity Through Action on the Social Determinants of Health. Final Report of
the Commission on Social Determinants of Health. Geneva: CSDH, World Health Organization.
Deogaonkar, Milind. 2004. Socio-Economic Inequality and Its Effect on Health Care Delivery in India: Inequality
and Health Care. Electronic Journal of Sociology 8 (1). ISSN: 11983655.
Dreze, Jean, and Amartya Sen. 2013. An Uncertain Glory: India and its Contradictions. London: Penguin Books.
Government of India (GoI). 1946. Report of the Health Survey and Development Committee Survey. Delhi:
Manager of Publications, GoI.
Government of India (GoI). 1980. Report on the First Backward Classes Commission. Vol I& II. GoI. Accessed
July 17, 2015 http://ncbc.nic.in/User_Panel/UserView.aspx?TypeID=1161.
International Institute for Population Sciences (IIPS). 2010. District Level Household and Facility Survey,
(DLHS-III), 200708. Mumbai, India: IIPS.
Jacob John, T. 2005. Bird Flu: Public Health Implications for India. Economic and Political Weekly 40 (46):
47924795.
Jacob John, T., and Jayaprakash Muliyil. 2009. Pandemic Inuenza Exposes Gaps in Indias Health System.
Indian Journal of Medical Research 130: 101104.
Jacob John, T., L. Dandona, V. P. Sharma, and M. Kakkar. 2011. India: Towards Universal Health Coverage 1,
Continuing Challenge of Infectious Diseases in India. Lancet 377: 252269.
Kochukuttan, Smitha, T. K. Sundari Ravindran, and Suneeta Krishnan. 2013. Evaluating Birth Preparedness and
Pregnancy Complications Readiness Knowledge and Skills of Accredited Social Health Activists in India.
International Journal of MCH and AIDS 2 (1): 121128.
Kumar, Supriya, and Sandra C. Quinn. 2012. Existing Health Inequalities in India: Informing Preparedness
Planning for an Inuenza Pandemic. Health Policy and Planning 27 (6): 516526.
Ministry of Health and Family Welfare (MoHFW). Govt. of India (GoI). 2007. The National Family Health Survey
(20052006). Vol. 1 and Vol. 2. Mumbai: International Institute of Population Sciences. Accessed August 1,
2014 http://dhsprogram.com/pubs/pdf/FRIND3/FRIND3-Vol1AndVol2.pdf.
Ministry of Health and Family Welfare (MoHFW). 2009. The National Health Bill, 2009 (Draft). New Delhi:
MoHFW. Accessed March 11, 2014 www.mohfw.nic.in/nrhm/Draft_Health_Bill/.../Draft_National_Bill.
Ministry of Health and Family Welfare (MoHFW). Government of India (GoI). 2011. Annual Report to the People
on Health. MoHFW, GoI.
Ministry of Health and Family Welfare (MoHFW). Government of India (GoI). 2014. National Health Policy 2015
(Draft). New Delhi: MoHFW. Accessed January 8, 2015 www.mohfw.nic.in.
Minnery, Mark, E. Jimenez-Soto, S. Firth, K. H. Nguyen, and A. Hodge. 2013. Disparities in Child Mortality
Trends in Two New States of India. BMC Public Health 13: 779.
Nussbaum, Martha C. 1997. Capabilities and Human Rights. Fordham Law Review 66 (2): 273300.
Nussbaum, Martha C. 2001. Women and Human Development. Cambridge, UK: Cambridge University Press.
Nussbaum, Martha C. 2003. Capabilities as Fundamental Entitlements: Sen and Social justice. Feminist
Economics 9: 3359.
Planning Commission. Government of India (GoI). 2008. 11th Five Year Plan (20072012), Social Sector, Vol. 2.
New Delhi: Planning Commission, GoI.
Planning Commission. Government of India (GoI). 2011. High Level Expert Group, Report on Universal Health
Coverage. New Delhi: Planning Commission, GoI.
Planning Commission. Government of India (GoI). 2011a. Report of the Working Group on Disease Burden for the
12th Five Year Plan (WG 3(1)): Communicable Diseases. New Delhi: Planning Commission, GoI.
Planning Commission. Government of India (GoI). 2011b. Report of the Working Group on Tertiary Care
Institutions for the 12th Five Year Plan (20122017) (WG2): Tertiary Care Institutions. New Delhi:
Planning Commission, GoI.
Planning Commission. Government of India (GoI). 2012. Five Year Plans. Planning Commision, GoI. Accessed
August 21, 2014 http://planningcommission.nic.in/plans/planrel/veyr/default.html.
Planning Commission. Government of India (GoI). 2013. 12th Five Year Plan (20122017), Social Sector. Vol. III.
New Delhi: Planning Commission, GoI.
Ruger, Jennifer Prah. 1995. Health, Health Care and Incompletely Theorized Agreements. Harvard University,
Mimeograph.
Ruger, J. 1998. Aristotelian Justice and Health Policy: Capability and Incapability Theorized Agreements.
Harvard University PhD Dissertation.
Ruger, Jennifer Prah. 2003. Health and Development. Lancet 362: 678.
Ruger, Jennifer Prah. 2004. Health and Social Justice. Lancet 364: 10751080.
Ruger, Jennifer Prah. 2006a. Health, Capability and Justice: Toward a New Paradigm of Health Ethics, Policy and
Law. Cornell Journal of Public Policy 15 (2): 101187.
580 R. Chakraborty & C. Chakraborti

Ruger, Jennifer Prah. 2006b. Toward a theory of a Right to Health: Capability and Incompletely Theorized
Agreements. Yale Journal of Law and Humanities 18(2): 273326.
Ruger, Jennifer Prah. 2006c. Ethics and Governance of Global Health Inequalities. Journal of Epidemiology and
Community Health 60 (11): 9981003.
Ruger, Jennifer Prah. 2006d. The Moral Foundations of Health Insurance. Quarterly Journal of Medicine,
doi:10.1093/qjmed/hcl130.
Ruger, Jennifer Prah. 2007. Rethinking Equal Access: Agency, Quality, and Norms. Global Public Health 2 (1):
86104.
Ruger, Jennifer Prah. 2008. Ethics in American Health 2: Ethical Approaches to Health Policy. American
Journal of Public Health 98 (10): 17561763.
Ruger, Jennifer Prah. 2009. Health and Social Justice. Oxford: Oxford University Press.
Ruger, Jennifer Prah. 2010. Health Capability: Conceptualization and Operationalization. American Journal of
Public Health 100 (1): 4149.
Ruger, Jennifer Prah. 2011. Shared Health Governance. The American Journal of Bioethics 11 (7): 3245.
Ruger, Jennifer Prah. 2012. An Alternative Framework for Analyzing Financial Protection in Health. PLOS
Medicine 9 (8): e1001294.
Sen, Amartya. 1984. The Living Standard. Oxford Economic Papers, 36.
Sen, Amartya. 1992. Inequality Reexamined. New Delhi: Oxford University Press.
Sen, Amartya. 2004. Why Health Equity?. In Public Health, Ethics, and Equity, edited by Sudhir Anand,
Fabienne Peter, and Amartya Sen, 2133. New Delhi: Oxford University Press.
Sen, Amartya. 2009. The Idea of Justice. Cambridge: The Belknap Press.
Sharma, Arun Kumar. 2009. National Rural Health Mission: Time to Take Stock. Indian Journal of Community
Medicine 34 (3): 175182.
The Economic Times (ET). PTI. July 8, 2014. Chhattisgarh highest incidence of poverty: C Rangarajan panel.
PTI. Accessed July 8, 2015. http://articles.economictimes.indiatimes.com/2014-07-08/news/51191636_1_
poverty-line-least-proportion-tendulkar-committee.
United Nations Development Programme (UNDP). 2014. Human Development Report 2014 Sustaining Human
Progress: Reducing Vulnerabilities and Building Resilience. New York: UNDP.
Vart, Priya, Ajay Jaglan, and Kashif Shaque. 2015. Caste-based Social Inequalities and Childhood Anemia in
India: Results from the National Family Health Survey (NFHS) 20052006. BMC Public Health 15: 537.
doi:10.1186/s12889-015-1881-4.
Whitehead, Margaret. 1992. The Concepts and Principles of Equity in Health. International Journal of Health
Service 22: 429445.
World Bank. 2015. India Overview. Accessed July 8, 2015 http://www.worldbank.org/en/country/india/overview#1 .
Yeravdekar, Rajiv, V. R. Yeravdekar, M. A. Tutakne, N. P. Bhatia, and M. Tambe. 2013. Strengthening of Primary
Health Care: Key to Deliver Inclusive Health Care. Indian Journal of Public Health 57 (2): 5964.

About the Authors

Rhyddhi Chakraborty (Ph.D. Indian Institute of Technology Kharagpur, India; M. Phil.
Univ. of Calcutta, India) keeps a varied interest in Applied Ethics especially in Bioethics,
Infectious Disease Ethics, and Environmental Ethics. Her current research interest is in the
philosophical social justice theory of Health Capability.

Chhanda Chakraborti (Ph.D. Univ. of Utah; M.A. Univ of Washington) is a professor of

Philosophy in the Department of Humanities and Social Sciences, Indian Institute of Tech-
nology Kharagpur, India. Her active research interest includes bioethics and public health
ethics.